When Jennifer Crow started taking methotrexate for her inflammatory arthritis and Myasthenia gravis, the doctor warned her it could take as many as six months to start seeing some benefit. Myasthenia gravis is a neuromuscular disease that causes weakness in the skeletal muscles.
“But within two to three weeks, I was already seeing a difference,” Crow tells Inverse.
Before methotrexate, family members had to help her every time she wanted to move about. Once she switched to methotrexate, however, everything changed.
“I can now walk [to my garden] by myself. I can sit down, I can stand up. I can do those things unassisted,” she says.
But over July 4th weekend, Crow, who lives in Tennessee, received a message from her pharmacy saying her prescription was “on hold or denied” and she needed to contact her provider if she wanted it refilled.
“I’ve never gotten that message for methotrexate before; it’s supposed to just get refilled. Before Roe was overturned, there was chatter about methotrexate specifically being named in Tennessee’s trigger law,” she says, referencing laws passed in states that automatically take effect 30 days after Roe is overturned. “And that’s when it occurred to me that it might be because of Roe v. Wade,” she says.
The Supreme Court’s decision overturning Roe v. Wade — abolishing a federally protected right to abortion — has far-reaching implications, well beyond terminating a pregnancy. As Crow learned, medications largely unrelated to pregnancy termination are being mired in confusion over uncharted legal territory.
Why is methotrexate affected by the Supreme Court’s decision about abortion?
One of the biggest ironies about methotrexate being pulled into the abortion mess is that it’s not typically associated with medication abortion.
Donald Miller, a professor in North Dakota State University’s School of Pharmacology tells Inverse, that methotrexate is primarily used for people like Crow who have inflammatory arthritis. However, it’s sometimes used off-label in the “very specific case of an ectopic pregnancy” which occurs when a fertilized egg implants outside the uterus. Ectopic pregnancies are not viable pregnancies and can be extremely dangerous for the person who is pregnant.
“Only about 10 percent of ectopic pregnancies are treated with methotrexate because you have to catch the ectopic pregnancy early for it to work,” Miller says. Methotrexate can only be used for an ectopic pregnancy within the first six weeks of pregnancy.
It’s used in such cases because the drug inhibits enzymes integral to cell reproduction and growth.
This cellular growth inhibition means taking methotrexate during pregnancy can result in severe birth defects; the manufacturer advises “females of reproductive potential to use effective contraception during Methotrexate Injection treatment and for six months after the final dose.”
That means most people who take methotrexate are either unable to become pregnant or are on at least one form of birth control.
Because of the risk of severe birth defects, a patient who does become pregnant while taking methotrexate, the Arthritis Foundation notes, “may decide to terminate the pregnancy. The reversal of Roe makes this decision far more difficult, especially in states that have actively banned or restricted the procedure.”
What conditions does methotrexate treat?
Kevin Hackshaw, Chair of the University of Texas Austin’s Rheumatology Department tells Inverse, “Methotrexate is one of the pillar medications for rheumatology. It is particularly important for use in rheumatoid arthritis where it has a long history of decreasing disease severity.”
Methotrexate can also improve the efficacy and longevity of other medications, including those for rheumatoid arthritis and lupus, he says. Additionally, it is “particularly helpful in allowing us to decrease the dosages of steroids required for many inflammatory disorders,” he adds.
Hackshaw says an estimated 70 to 80 percent of rheumatoid arthritis patients take methotrexate and 25 percent of lupus patients are on the drug.
“Since one to two percent of the U.S. population has rheumatoid arthritis, this means it is a very frequently used medication,” he says. “It is the safest and has the best track record of this category of medications for use with these types of conditions.”
It’s so safe and effective that “insurance companies often require that you have to try methotrexate before trying other drugs,” Miller says.
Methotrexate is also used in other autoimmune and inflammatory disorders like inflammatory bowel disease and psoriasis, as well as some cancers, he adds.
Legal battles over methotrexate ahead
Legal battles over the issue are almost certainly on the horizon.
“One of the problems right now is that everyone is confused about what we can and can’t do,” Miller says of providers. “Even large health systems are saying ‘don’t prescribe methotrexate until we figure this out.’ But a delay of just a few weeks has a big impact on patients.”
How laws are interpreted may come down to “individual county prosecutors,” Miller says. “They may have their own agenda for interpreting laws in certain ways. Some of these anti-abortion laws are written pretty vaguely because they were passed without any understanding of the nuances.”
Those vague, ill-informed laws are confusing for healthcare providers and patients alike.
“Prescribers and pharmacists are being very careful. There’s a lot of fear. And I think in some cases, inappropriate fear. So the reaction is all over the board...ultimately this will be litigated, probably at the federal level.”
Methotrexate, as well as medications approved for pregnancy termination, are regulated by the Food and Drug Administration, and individual states generally don’t have the ability to totally ban something approved at the federal level.
Already, a manufacturer of mifepristone, which is used in medication abortion, is arguing that a state can’t preempt the FDA. There is some precedent for the argument; in 2014, a judge ruled that Massachusetts couldn’t ban the painkiller, Zohydro, because it was FDA-approved.
Texas, where Hackshaw practices, has some of the most restrictive abortion laws in the country, with a “trigger law” set to further restrict abortion 30 days after the fall of Roe. That’s July 23rd. Once the trigger law takes effect, “Anyone who provides or attempts to provide an abortion will be charged with a first- or second-degree felony, and will be subject to a civil penalty of at least $100,000 for each violation.” There are some exceptions if the mother’s life is in serious danger.
While Hackshaw says he hasn’t faced “any pushback” for prescribing methotrexate, he says he “has concerns” about that happening.
What prescribers need to know about methotrexate
When it comes to methotrexate, Miller suggests doctors write the reason they’re prescribing the drug directly on the prescription. That’s what Crow’s doctor did after Crow contacted her to let her know the refill had been denied.
“She wrote an entirely new prescription and noted that it was for rheumatoid arthritis on the prescription” Crow recalls. She was ultimately able to get her medication through the new prescription. But others might not be as lucky as Crow.